History of Cesarean Birth

Mar 23 2009

A cesarean delivery is the birth of a baby via surgery performed through the abdominal and uterine walls. Cesarean is the most common operation in the United States. Since the latter half of the twentieth century, the operation has increased in safety, in part because of the availability of trained anesthesiologists and obstetricians, and capable pediatricians to care for the newborn after the operation. The use of better surgical techniques, blood transfusion, and antibiotics also have helped.

Rates of Cesarean Birth

In 1965, approximately 4.5 percent of births were cesarean births. By 1988, this had risen spectacularly to almost 25 percent of all births . A small but steady decline followed, persisting through 1997. In 1998, the cesarean rate in the U.S. was 21.1 percent, rising to 22 percent in 1999. The recent rise in rate is mostly among women who had not had a previous cesarean, although there also has been a decline in the rate of vaginal birth after cesarean(VBAC).

The reasons for the upward, downward, and again upward trends in cesarean births are varied. Specific changes that took place in both society and obstetrical practices in the second part of the twentieth century were responsible for the increase in cesarean rates, in addition, of course, to the continuing increased safety of the surgery itself.

One societal change was that women began to have fewer babies, meaning a higher percentage of births occurred to nulliparas-women who’d never had a child before. These pregnancies tend to have more complications, or to be treated as more at risk by physicians. In addition, women are having babies at older ages than previously. This does not necessarily incur increased risk, but some of these women have medical problems such as diabetes and high blood pressure that are less common in younger women.

A major change in obstetrical practice has been the use of electronic fetal monitoring. This has led to the performance of more cesarean deliveries for fetal problems, although it has not improved newborn outcomes. In addition, babies in the breech presentation have been delivered more and more frequently by cesarean. In 1990, 83 percent of all breech babies were born by cesarean. During this same time, the use of forceps has decreased. High forceps, are no longer practiced. Some babies that would have been delivered by forceps are now delivered by cesarean.

In looking at whether the rate of cesarean birth is appropriate, one must consider the fact that the surgery does incur significantly increased risks to the mother: discomfort, due to an abdominal operation and an increased likelihood of infection, the need for more extensive anesthesia, hemorrhage from unavoidable surgical accidents, and the increased need for a repeat cesarean in subsequent pregnancies.

The risk of maternal death from cesarean is several times that of vaginal birth. Still, it is extremely small-about 1 in 10,000 births. If this is weighed against the chance of fetal injury from a delay in delivery or a difficult birth-both events avoidable by cesarean-the decision in equivocal situations is likely to be in favor of cesarean.

Yet, once the cesarean rate reached one-quarter of all births, there was a public outcry against so many surgeries performed for what is usually a normal body function. In the publication Healthy People 2000, the federal government called for a lowering of the cesarean rate. The rate of cesarean birth in the United States is much higher than in a number of developed countries in Europe, especially for cesareans attributed to previous cesarean and dystocia-difficult labor. Dystocia is often a somewhat subjective diagnosis and how quickly a physician or midwife intervenes in the case of slow progress of labor can vary greatly among practitioners.